Goals and Aims: The goal of this study is to reduce the risk of preventable readmission for heart failure (HF) patients transitioning from inpatient to ambulatory care. The specific aims of this study are: 1) To develop a broadly applicable operational model of idealized inpatient-ambulatory transitions; 2a) To use Failure Mode and Effects Analysis (FMEA) to identify the key failure modes (and their causes) in inpatient/outpatient transitions of care that contribute to preventable readmissions, 2b) To use FMEA to refine the model and to identify the key capabilities necessary to minimize preventable readmissions; and 3) To develop and pilot test a draft "transitional capability assessment" tool that can be used to evaluate an entity's ability to deliver high quality transitional care. Background: The inpatient-to-ambulatory care transition is a complex process that carries with it the risk of medical errors, adverse drug events, and, when the transition is poorly managed, it may even lead to preventable inpatient readmission. An effective transition requires [unreadable] that 4 key steps be completed: notification, transfer of information, transfer of responsibility, and care plan oversight. Methods: With stakeholder input, we will develop an "ideal" model of transitional care for HF that is designed to reliably accomplish the 4 key steps. We will conduct a FMEA of the ideal model to identify sources of risk and the capabilities necessary to reduce those risks. We will then conduct a gap analysis to test the validity of the ideal model; the ideal model will be applied to transitional care for a different condition (bypass surgery) and in different care environments. Finally, using FMEA and gap analysis results, we will develop an initial draft of a "transitional care capability" assessment tool to aid other organizations to assess whether a healthcare entity (e.g. hospital, provider) has the necessary capabilities to provide high quality transitional care. The draft instrument will be used by Geisinger's RHIO partners as a preliminary assessment of its validity. Relevance: Preventable hospital readmission is a problem associated with the complex process of transitioning a patient to primary care management following a hospital admission for heart failure treatment. This study aims to reduce the rate of preventable hospitalizations by developing a new model for transitional care, using risk analysis to make sure it is safe, and then developing a tool that can be used to assess whether a healthcare entity can provide quality transitional care. [unreadable] [unreadable] [unreadable]